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Court faces up to a gender divide

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The case of 13-year-old "Alex" has reignited controversy over a little-understood area of medicine, writes Deborah Gough.

Family Court Chief Justice Alistair Nicholson this week ruled that a 13-year-old Australian girl could begin treatment to become a boy. "Alex" will immediately begin a course of hormones, of the same type as the contraceptive pill, to suppress menstruation. At 16, "he", as the Chief Justice referred to Alex, can begin a course of testosterone. This will deepen her voice and promote the growth of facial hair, muscular development and an enlarged clitoris.

The judge agreed with psychiatric assessments that Alex has dysphoria, a medical condition that results in a mismatch between the gender a person believes themselves to be and the physical sex of their body.

Court orders prevent much being written about Alex, but The Age can write that she was born overseas and that she adored her father, who treated her as a boy. He taught his daughter karate and self-defence.

When her father died, when Alex was five or six, she was devastated. The family migrated to Australia. Her mother has no contact with Alex or her family, including Alex's aunt, with whom she lives.

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Child protection workers were first alerted to Alex's situation nine months after the family arrived in Australia in 2000. She is under the guardianship of a government department, who brought the case to court with the support of her aunt and school after Alex started to develop suicidal and self-harming tendencies when she entered puberty.

When Alex was enrolled in a faith-based primary school (she is now at high school), her principal and teacher described how she refused to stand in either the boys' line or girls' line at school assembly. She played cricket and arm-wrestled boys on school camp.

While puberty is indeed a troubling time, Lauren Christopher, convener of TransGender Victoria, says questions about gender identity can start at any age: "You just know, most people say they have always known, they may not have given it a name, but they knew."

If we are going to have these sorts of treatments . . . we need a model where there are centres of excellence. LOUISE NEWMAN, Royal Australian and New Zealand College of Psychiatrists

The one Australian clinic that deals exclusively with questions about gender identity, the Gender Dysphoria Clinic, is based at Monash Medical Centre and only treats adults. In the past 29 years, it has performed about 600 gender reassignment operations. Some Australians travel overseas to Thailand and Canada for surgery. Generally, dysphoria specialists use the Harry Benjamin International Gender Dysphoria Association standards of care, which state that a person must live in their preferred gender full-time for one year and seek the counsel of two psychiatrists and an endocrinologist before transition can begin.

At the Gender Dysphoria Clinic, patients must have a doctor's referral. They must also write a letter explaining their feelings and describing the impact of their condition on their lives.

If the clinic agrees to see them, they regularly meet with two psychiatrists and possibly a psychologist as well. They must live full-time in their nominated gender for 18 months before surgery. If the two psychiatrists agree, hormone therapy may start while patients are living in their nominated sex.

Dr Louise Newman, the chair of the Faculty of Child and Adolescent Psychiatry of the Royal Australian and New Zealand College of Psychiatrists, says regulations are needed to help professionals decide when and how best to deal with gender identity and dysphoria.

"If we are going to have these sorts of treatments available, then ethically and clinically we need a model where there are centres of excellence," Dr Newman says.

Katherine Cumming, resource and development worker for support service the Gender Centre, says some people also take dangerous risks by self-medicating to speed up the process.

"I am also quite sure there are a number of doctors that do things off the record. We know that lots of doctors want to relieve people of their great suffering by helping with hormone therapy," Cumming says.

Awareness about teenage dysphoria is growing. Five years ago, there were four support groups in Melbourne for gay, lesbian, bisexual and transgender people - there are now 34 across the state.

The growth in services followed a 1999 La Trobe University study which found that young homosexuals were four times more likely to consider suicide than heterosexuals.

A Joy FM radio show Transmission Time co-host, Sally Goldner, says some progress in raising awareness about transgender issues has been made. She hopes to develop a transgender mentoring program.

"I think young people are becoming more aware of it, and the internet has made a massive difference. They can ask questions safely and get some answers," Goldner says.

"It is going to be hard when he goes to the beach and all the guys are in their shorts when it's 39 degrees at Bondi. Sure he is going to have issues, but he has the freedom to live his life now and he has a choice."